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CLj MONI QRI *A 01, �� �`�1�G SYSTEM CERTIFr��TIO 2009 For Use Bar.-Ill Jtu•i,sdiclions Il itlrirr the Staler of Cah err'wim-of,waf�lL�� r r .41(thority C'iled: Chapter 67, Health aml Srr 101 Cade; Chapter 16, Division 3, Title?. ?` ,p t !!"I{cf Pfr r�'et alations This forth inttst be used to document testing and servicing of monitoring etluipmcnt. A Separate certification or report must be prepared for each monitoring system eor�1-tra! Hanel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator, The owner/operator Inust submit a copy of th within 30 days of test date. is faint to the local agency regulating UST systems A. General Information Facility Name: _S�� Site Address: �� oo Bldg,No.: {� fl City: S�(��YT�� Zip: Facility Contact Person: �IY1QAnA a U Contact Phone No,:(__7 1Zj 1 fvPake/ModeP of Monitoring System: V (� TLS _ S_� --L� Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the: ro ariare hales to indicates ecific a ai ulent Ins ected/semicecl: Tank iD, � P,C" ` () , ❑ In-Tank Gau in Probe. Tank ID: j g g Model:4 1r14(� / M In-Tank Gauoina Probe � Annular Space or Vault Sensor. Model: t Model: i 40 Piping SUMP/Trench Sensor(s). Model: Ell Annular Space or Vault Sensor. Model: A Fill Surnp Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model:- ❑ Mechanical Line Leak Detector. Model: 22 if Sump Serhsor{s). Model: ❑ Electronic Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Other(speci equipment t e and anode!in SectionQ Tank E on Pa e 2). L3 OtherOv eciifyleH' gfi�aaent tvLevel Serand n oriel in Section E on Pare 2}. sor. Model: Tank ID: W In-Tank Gauging Probe. Model: Tani(ID: M Annular Space or Vault Sensor. Model; / O in-Tank Gauging Probe. Model: 1/0ElAnnu1 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensoa•{s). Model: 1 ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Me Sump l LineSensoLe Model: ❑ Electronic Line Leak Detector. Model: C3 Mechanical Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Electronic Line Leak Detector. Model: ❑ Other(s jecia a ui.nherht ty e and model in Section E on Page? . ❑ Tank Overfill/High-Level Sensor. Model: �} } ❑ Other(specify et rri)nherat Iv)e and mode!in Section E on Pit 2), Dispenser JD-. l sf `/ 3."I f .{/r1 h siiyrr' 0 Dispenser Containment Sensor(s). Model: + Dispenser ID: ❑ Shear Valve(s). — "( ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Floats)and Chain(s). ❑ Shear Valve(s), Dispenser ID: (7.-'c- n 3 CJ Dis ease,-Containment Float(s)and C'hain(s). P, G3 Dispenser ID: Qispenser Containment Sensor(s). Model: EJShear Valve(s). ?t� ❑ Dispenser Containment Sensor(s), Model: 13 Dis.enser Containment Float(s)and Chain(s). ❑ Shear Valve(s). Dispenser f D: r J f 77 J ❑ Dispenser Containment Float(s)and Chain(s). Q Dispenser Containment Serhsor(s). Model: Dispenser ID: ❑ Shear Valve(s). ' ❑ Dispenser Coil tainnheni Sensor•(s), Model: ❑Dis enser Containanent Float(s)and Chain(s). ❑ Shear Valve(s). ❑ Dis enser Containment Fioat(s)and Chain(s}, `lfthe facility contains more tanks or dispensers,cttpy this form. Include it fol- tioah for every tank and dispenser at(he facility. C. Certification - i eel-tify tlnit e4 ue;en ��l � ,f manufacturers' guidelines. Attached le this Certification i5 inlirnm altiondee„naent was inspected/serviced in accordance with the information is eurrect and a Plot PI:an Showing the lapout of monitoring equitfrna nt, F�re'")' etluiptntentncapable of generatiecessary to verif� ngtsucll reports,I have also attached a copy of the report; (cheek all ihca apple): P Sy Technician Name(print): set-up ,I�' Alarm Ihistor•y report Si3nature: Certification No.: s�' ! ]°(' cC ZF 52 3 '7'3-LST License.No.; Z�G �_(�24 Testing Company Name: `s Phone No.:{ 2(? 'f'l� 6112, Site Address: r./(( (? <; f r ' . o14 t. Date of Testing/5etvicithg: 2 / j ltlaraiforfng Systertta titivation Page I of3 03101 b -V\7 .1